Does decreased fetal growth estimation in the appropriate for gestational age range affect delivery outcomes?

PURPOSE: To study the effect of decreased estimated fetal weight (EFW) percentiles in appropriate for gestational age fetuses. METHODS: This retrospective cohort study included women who had second and third trimester ultrasound examinations. Delivery and neonatal outcomes of pregnancies with decreased EFW of ≥ 30 percentiles in EFW between ultrasound examinations (decreased growth group) and those without such a decrease (control group) were compared. Deliveries with EFW or birthweight below the 10th percentile were excluded. RESULTS: Among 1610 deliveries, 57 were in the decreased growth group and 1553 in the control group. Maternal characteristics did not differ between the groups except for higher rate of nulliparity in the decreased growth group. We found similar rates of Category II/III monitoring, cesarean deliveries due to non-reassuring fetal heart rate and adverse neonatal outcomes. Neonatal birthweight was lower in the decreased growth group as compared to controls. CONCLUSIONS: This study did not find association between the group of appropriate for gestational age fetuses with decreased growth, with adverse outcomes.

Adverse outcomes in vacuum-assisted delivery after detachment of non-metal cup: a retrospective cohort study.

PURPOSE: To evaluate neonatal and maternal outcomes associated with detachment of non-metal vacuum cup during delivery and to identify risk factors for these detachments. METHODS: This retrospective cohort study included women with singleton pregnancy, who underwent vacuum-assisted vaginal delivery with a non-metal vacuum cup in a single academic institution, January 2014-August 2019. Failed vacuum deliveries were excluded. Primary outcomes were defined as subgaleal hematoma (SGH) and cord blood pH < 7.15. Secondary outcome included other neonatal complications and adverse maternal outcomes. Outcomes were compared between vacuum-assisted deliveries with and without cup detachment during the procedure. RESULTS: A total of 3246 women had successful VAD and met the inclusion criteria. During the procedure, the cup detached at least once in 665 (20.5%) deliveries and did not detach in 2581 (79.5%). The cup detachment group experienced higher rates of SGH (8.9% vs. 3.5%, p = 0.001) and cord blood pH < 7.15 (9.8% vs. 7.1%, p = 0.03). There were also more neonatal intensive care unit admissions (NICU) (4.4% vs. 2.7%, p = 0.03) and more fetuses with occiput posterior position (70.8% vs. 79.4%, p = 0.001), the vacuum duration was slightly longer (6 ± 3.7 vs. 5 ± 2.9 min) and more neonates had birth weights > 3700 g (14.1% vs, 10.3%, p = 0.006). Interestingly, there were more males in that group (60.6 vs. 54.6, p = 0.005). All these factors remained significant after controlling for potential confounders. CONCLUSIONS: Vacuum cup detachment has several predictive characteristics and is associated with adverse neonatal outcomes that should be incorporated into decisions made during the procedure.

Can we improve our ability to interpret category II fetal heart rate tracings using additional clinical parameters?

OBJECTIVES: This study examined predictive factors, in addition to Category II Fetal Herat Rate (FHR) monitoring that might imply fetal acidosis and risk of asphyxia. METHODS: This retrospective cohort study compared three groups of patients with Category II FHR monitoring indicating need for imminent delivery. Groups were divided based on fetal cord blood pH: pH≤7.0, 7.0

The role of mediolateral episiotomy during vacuum-assisted vaginal delivery with soft cup devices.

PURPOSE: This study evaluated whether episiotomy during vacuum-assisted delivery leads to fewer third- and fourth-degree tears. METHODS: This was a retrospective cohort study of all nulliparas who underwent a singleton, soft cup, vacuum-assisted vaginal delivery in one institution, from January 2014 to August 2019. Failed vacuum deliveries were excluded. Based on power analysis calculation, a sample size of 500 women in each group was sufficient to detect an advantage of episiotomy, if present. Primary outcome was third- or fourth-degree perineal tear. Secondary outcomes were other maternal complications, and low neonatal cord pH and Apgar scores. Outcomes were compared between women with and without episiotomy. RESULTS: During the study period, 2370 nulliparas had a vacuum-assisted vaginal delivery using soft vacuum cup and met the study inclusion criteria. Episiotomy was performed in 1868 (79%) women, and 502 (21%) delivered without episiotomy. Background characteristics were similar in both groups. There were no significant differences in the rates of third and fourth grade perineal lacerations between the two groups. Episiotomy was associated with higher rate of postpartum hemorrhage (p < 0.01) CONCLUSIONS: Using selective episiotomy for patients delivering vaginally with the assistance of soft cap vacuum does not increase third- or fourth-degree perineal tears.

Does parity affect pregnancy outcomes in the elderly gravida?

PURPOSE: To identify whether older primiparas have more complications than do women who continue to deliver children into their late reproductive age. Patients of at least 35 years of age at delivery were included. Within this cohort, data from primiparous and multiparous women were compared. METHODS: This retrospective study was based on electronic medical records from a single academic center, with more than 7000 deliveries annually. The impact of parity on maternal complications was assessed using a multivariate logistic regression model that adjusted for baseline maternal characteristics and medical history. RESULTS: During the study period, there were 54 283 deliveries in our medical center. A total of 13,982 (25.7%) patients were at least 35 years old at delivery. The rate of twin pregnancy was higher in the primiparous group (1.9%) as compared to the multiparous group (0.8%, 95% CI 0.30-0.64, P < 0.001), as was the incidence of delivery prior to 34 weeks (6.1% of the primiparas versus 2.9% of the multiparas, P < 0.001, OR 2.16, 95% CI 1.75-2.68); hypertensive disorders (3.9% versus 1.7%, P < 0.001, 95% CI 0.33-0.57); diabetes (4.6% versus 3.2%, P = 0.003, 95% CI 0.55-0.88); and IUGR (10.5% versus 4.7%, P < 0.001, 95% CI 0.35-049), respectively. The increased risk for pre-term delivery, hypertensive disorders, diabetes, and IUGR was maintained after logistic regression analysis. CONCLUSION: We found that pregnancy complications typical to older parous women are significantly more common among primiparas, indicating that not only older age, but also having a first child relatively late in the reproductive period contributes to adverse pregnancy outcomes.

Neonatal outcomes of pregnancy-associated breast cancer: Population-based study on 11 million births.

BACKGROUND: As the age at first pregnancy continues to rise in the United States so does the incidence of breast cancer diagnosed during pregnancy. Our objective was to evaluate temporal trends in the incidence of pregnancy-associated breast cancer (PABC) and to measure neonatal outcomes associated with PABC. METHODS: We conducted a population-based cohort study using the 1999-2012 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) from the United States. Logistic regression models, adjusted for maternal baseline characteristics, examined the effect of PABC on neonatal outcomes. RESULTS: There were 11 846 300 deliveries between 1999 and 2012, of which 772 cases of PABC were identified, resulting in an overall incidence of 6.5 cases/100 000 pregnancies. There was a significant increase in the incidence of PABC during the study period (P < 0.05). Women with PABC tended to be older, of white ethnicity, belong to a higher income quartile and to be treated in an urban teaching hospital. In pregnancies complicated by breast cancer, there was a greater risk of preterm delivery (OR 4.84, 95% CI 4.05-5.79) and preterm premature rupture of membranes (OR 1.79, 95% CI 1.06-3.05). No associations were observed between PABC and intrauterine growth restriction, congenital anomalies or intrauterine fetal demise. CONCLUSION: There is an uptrend in the incidence of PABC and therefore, the need for counseling these patients is also increasing. Although pregnancies with the diagnosis of maternal breast cancer are more prone to premature births, it is encouraging that these babies do not appear to be at increased risk for congenital anomalies, growth restriction, or fetal demise.

The effect of assisted reproductive technology on the incidence of birth defects among livebirths.

PURPOSE: Our study objective is to examine the association between births conceived with assisted reproductive technology (ART) and birth defects using a large database from the United States. METHODS: Using the Centers for Disease Control and Prevention's Period-linked birth-infant death data files and fetal death database for 2011-2013, we conducted a retrospective cohort study comprised of live births that occurred in the USA during that time. Multivariate logistic regression was used to estimate the association between ART and birth defects, both overall and by specific defects. RESULTS: There were 11,862,780 live births between 2011 and 2013. Of these births, 11,791,730 were spontaneous pregnancies and 71,050 were conceived by ART, with an increasing trend in incidence of ART during the study period and an overall increasing trend of birth defects. Overall, infants conceived by ART had a greater risk of having birth defects than did infants conceived spontaneously (77/10,000 vs 25/10,000, respectively, OR 2.14, 95% CI 1.94-2.35). The malformations most commonly associated with ART were cyanotic heart defects (OR 2.74, 95% CI 2.42-3.09), cleft lip and/or palate (OR 1.47, 95% CI 1.14-1.89), and hypospadias (OR 1.77, 95% CI 1.42-2.19). There were no differences in risk of omphalocele or neural tube defects between the two groups. CONCLUSIONS: There is an overall and type-specific increased risk of birth defects in the ART population. Appropriate counseling and specialized ultrasound evaluations should be considered in pregnancies conceived by ART.

Perinatal outcomes of unplanned out-of-hospital deliveries: a case-control study.

PURPOSE: To compare the pregnancy and perinatal outcomes of unplanned home or car births vs. in-hospital deliveries. METHODS: A retrospective, case-control study of women who underwent unplanned out-of-hospital deliveries vs. in-hospital deliveries from 2004 through 2014. Matching was based on gestational age and parity in a ratio of 2:1. RESULTS: There were no significant differences between the groups regarding demographic criteria, prenatal care and delivery complications. Women who delivered out of hospital (n = 90) had significantly fewer cesarean deliveries (1.1 vs. 10.6%; p = 0.05) and operative deliveries (2.2 vs. 13.3%; p = 0.004) in their obstetrical history than did the control group (n = 180). Significantly more newborns delivered out of the hospital had polycythemia (25.6 vs. 1.7%; p < 0.0001) and hypothermia (3.3 vs. 0%; p = 0.036) compared to the control group. CONCLUSION: Women with unplanned out-of-hospital deliveries tend to have fewer complications in their previous deliveries. Higher rates of polycythemia and hypothermia require attention for neonates born out of the hospital.

Fertility treatment and dichorionic discordant twins - are they related?

OBJECTIVE: This prospective cohort study evaluated the relationship between fertility treatments and the prevalence and outcomes of dichorionic discordant twins. This issue has gained importance due to twin gestations resulting from fertility treatments. STUDY DESIGN: Mothers of dichorionic twin pregnancies achieved in a single fertility clinic by assisted reproduction techniques, who had completed the first trimester of the pregnancy, were prospectively enrolled. Pregnancies with major fetal anomalies were excluded. Data regarding concordant and discordant twins based on the fertility treatments given to achieve the pregnancies were analyzed to determine the prevalence of discordance and pregnancy outcomes. RESULTS: A total of 571 dichorionic twin pregnancies were available for evaluation. Fertility treatments modalities, sperm quality and implantation of cultured and thawed embryos did not influence the rate and severity of discordant twins. Increased hospitalization rates were found among discordant (n=108) compared to concordant (n=463) twins (47.2% vs. 31.3%, P<0.0001) and higher rates of betamethasone treatment (65.7% vs. 28.9%, P<0.0001). Secondary analysis of discordant pregnancies with a growth restricted twin, revealed the same results. We found no association between various fertility treatments and twin discordance. CONCLUSIONS: Our data suggest that fertility treatments do not play a major role in the pervasiveness and outcome of discordant twin pregnancies.

Premature rupture of the membranes at term: time to reevaluate the management.

PURPOSE: To compare maternal and neonatal outcomes in induced vs. expectant management of term PROM. METHODS: This retrospective study included patients with term PROM. A total of 325 were enrolled: 213 managed expectantly and 112 induced at admission and matched according to gestational age. Expectant management group patients were allowed to defer labour induction up to 48 h. Primary outcome measures were maternal or foetal signs of infection (chorioamnionitis, early neonatal sepsis or postpartum endometritis) and prolonged maternal hospitalization. Secondary outcome was caesarean delivery rate. RESULTS: All group characteristics were comparable except that expectant management included more nulliparous women. Women managed expectantly had a higher rate of prolonged hospitalization [15 (7 %) vs. 2 (1.8 %); P = 0.043] as an indication of maternal complications, compared to induction management. They also had a higher rate of caesarean delivery [34 (16.4 %) vs. 8 (7.1 %), respectively; P = 0.024]. Adjustment for parity did not change the results. Early neonatal outcomes were similar between groups. CONCLUSIONS: Expectant management increases the likelihood of caesarean delivery and prolonged maternal hospitalization. This should be considered when advising patients with term PROM regarding labour induction.

Patients with high-risk pregnancies and complicated deliveries have an increased risk of maternal postpartum readmissions.

OBJECTIVE: Postpartum readmission after initial hospitalization for delivery can be diminished if better understood. The aim of this study was to determine the risk factors and indications for maternal re-hospitalization after delivery, in order to identify preventable factors. STUDY DESIGN: This was a case control study based on retrospective cohort of patients who delivered at our institution. The patients that were readmitted within 2 weeks of their delivery were included in the study group while the control group was conducted from patients who delivered at the same time but were not re-hospitalized and included twice the number of patients. Demographic characteristics as well as pregnancy, labour and postpartum courses were compared between the two groups. RESULTS: A total of 227 women were re-hospitalized within 14 days after initial discharge. The control group consisted of 450 women. The demographic characteristics were similar among the two groups, so were the rates of obesity, gestational weight gain and smoking. The major indication for readmission was postpartum infections, most of which were not related to immediate postpartum febrile morbidity. Emergency cesarean section was found to be an independent risk factor for readmission. CONCLUSIONS: The rate of patients with high-risk pregnancies and complicated deliveries is higher among postpartum maternal readmissions. These data might suggest more cautious postpartum care for those patients.

Are reduced fetal movements "merely" a maternal perception or truly a reflection of umbilical cord complications? A clinical trial.

OBJECTIVE: To characterize obstetric outcomes and the association with umbilical cord (UC) complications among women complaining of reduced fetal movements (RFMs). METHODS: This retrospective cohort compared women with a perception of RFMs within 2 weeks prior to delivery with women who reported no changes in fetal movements in terms of maternal characteristics and neonatal outcomes. A primary outcome of UC complications at delivery was defined. Multivariable regression analysis was performed to identify independent associations with RFMs and UC complications. RESULTS: In all, 46 103 women were included, 2591 (5.6%) of whom reported RFMs and 43 512 (94.4%) in the control group. Compared with controls, the RFM group was more likely to be nulliparous (42.6% vs 32.2%, P < 0.001), smokers (6.4% vs 5.4%, P = 0.029), or obese (body mass index >30) (16.4% vs 11.6%, P < 0.001). They were also more likely to have an anterior placenta (56.2% vs 51.8%, P < 0.001) and poly/oligohydramnios (0.7% vs 0.4%, P = 0.015 and 3.6% vs 2.1%, P < 0.001, respectively). Induction of labor was more common in the RFM group (33.9% vs 19.7%, P < 0.001), as well as meconium (16.8% vs 15.0%, P = 0.026) and vacuum extractions (10.1% vs 8.0%, P < 0.001). Higher rates of stillbirth and the severe composite neonatal outcome were observed in the RFM group (1.5% vs 0.2%, P < 0.001 and 0.6% vs 0.3%, P = 0.010, respectively). The RFM group was characterized by higher rates of triple nuchal cord (P = 0.015), UC around body or neck (32.2% vs 29.6%, P = 0.010), and true knot (2.3% vs 1.4%, P = 0.002). Multivariable logistic regression found RFMs to be independently associated with triple nuchal cord and with a true cord knot. A sub-analysis including only cases of stillbirth (n = 127) revealed even higher rates of UC complications: 7% of all stillbirths presented with a true cord knot (20% true knots were found in stillbirths preceded by RFMs vs 6.1% in stillbirth cases without RFMs). Additionally, 33.8% of all stillbirths presented with nuchal cord (40% preceded by RFMs vs 33.3% without RFMs). CONCLUSIONS: RFMs are associated with increased risk of UC complications observed at delivery, as well as increased risk of stillbirth and neonatal adverse outcomes.

Cesarean Delivery Complicated by Peripartum Infection and Risk of Uterine Rupture During Subsequent Trial of Labor.

Background: Uterine rupture is a rare, but dangerous obstetric complication that can occur during trial of vaginal birth. Methods: The aim of this study was to evaluate the relationship between peripartum infection at the first caesarean delivery to uterine dehiscence or rupture at the subsequent delivery. We conducted a retrospective case-control study from March 2014 to October 2020 at a single academic medical center. The study group included women with a prior caesarean delivery and proven dehiscence or uterine rupture diagnosed during their subsequent delivery. The control group included women who went through a successful vaginal birth after cesarean section (VBAC) without evidence of dehiscence or uterine rupture. We compared the rate of peripartum infection during the first cesarean delivery (CD) and other relevant variables, between the two groups. Results: A total of 168 women were included, 71 with uterine rupture or dehiscence and 97 with successful VBAC as the control group. The rate of peripartum infection at the first caesarean delivery was significantly higher in the study group compared to the control group (22.2% vs. 8.2%, p = 0.013). Multivariate logistic regression analysis found that peripartum infection remained an independent risk factor for uterine rupture at the subsequent trial of labor after CD (95% confidence interval, p = 0.034). Conclusion: Peripartum infection in the first caesarean delivery, may be an independent risk-factor for uterine rupture in a subsequent delivery.

Head Injuries Related to Birth Trauma in Low Birthweight Neonates During Vacuum Extraction.

Introduction Preterm delivery (gestational age < 34 w) is a relative contraindication to vacuum extraction. Current data do not differentiate clearly between preterm delivery and low birthweight. We aimed to evaluate the impact of non-metal vacuum cup extraction on neonatal head injuries related to birth trauma in newborns with low birthweights (< 2500 g). Materials and Methods A retrospective cohort of 3377 singleton pregnancies delivered by vacuum extraction from 2014 to 2019. All were gestational age ≥ 34 w. We compared 206 (6.1%) neonates with low birthweights < 2500 g to 3171 (93.9%) neonates with higher birthweights, divided into 3 subgroups (2500-2999 g, 3000-3499 g, and ≥ 3500 g). A primary composite outcome of neonatal head injuries related to birth trauma was defined. Results The lowest rates of subgaleal hematoma occurred in neonates < 2500 g (0.5%); the rate increased with every additional 500 g of neonatal birthweight (3.5%, 4.4% and 8.0% in the 2500-2999 g, 3000-3499 g, and ≥ 3500 g groups, respectively; p = 0.001). Fewer cephalohematomas occurred in low birthweight neonates (0.5% in < 2500 g), although the percentage increased with every additional 500 g of birthweight (2.6%, 3.3% and 3.7% in the 2500-2999 g, 3000-3499 g, and ≥ 3500 g groups, respectively, p = 0.020). Logistic regression found increasing birthweight to be a significant risk factor for head injuries during vacuum extraction, with adjusted odds ratios of 8.12, 10.88, and 13.5 for 2500-2999 g, 3000-3499 g, and ≥ 3500 g, respectively (p = 0.016). NICU hospitalization rates were highest for neonates weighing < 2500 g (10.2%) compared to the other groups (3.1%, 1.7% and 3.3% in 2500-2999 g, 3000-3499 g, ≥ 3500 respectively, p < 0.001). Conclusions Vacuum extraction of neonates weighing < 2500 g at 34 w and beyond seems to be a safe mode of delivery when indicated, with lower rates of head injury related to birth trauma, compared to neonates with higher birthweights.

Spontaneous Preterm Birth: Elevated Galectin-3 and Telomere Shortening May Reflect a Common Pathway of Enhanced Inflammation and Senescence.

Preterm delivery complicates 5-12% of pregnancies and is the primary cause of neonatal morbidity and mortality. The pathophysiology of preterm labor and parturition is not fully known, although it is probably related to inflammation and placental senescence. Telomere shortening is related to senescence and galectin-3 (Gal-3) protein is involved in cell growth, differentiation, inflammation, and fibrosis. This study examined changes in Gal-3 expression and telomere homeostasis (which represent inflammatory and stress markers) in maternal blood and placental tissue of spontaneous preterm births (SPTB) and uncomplicated, spontaneous term pregnancies (NTP) during labor. Participants included 19 women with NTP and 11 with SPTB who were enrolled during admission for delivery. Maternal blood samples were obtained along with placental tissue for Gal-3 analysis and telomere length evaluation. Gal-3 protein expression in placental tissue was increased in SPTB compared to NTP (fold change: 1.89 ± 0.36, P < 0.05). Gal-3 immunohistochemistry demonstrated strong staining in placental extravillous trophoblast tissue from SPTB. Maternal blood levels of Gal-3 protein were elevated in SPTB compared to NTP (19.3 ± 1.3 ng/ml vs. 13.6 ± 1.07 ng/ml, P = 0.001). Placental samples from SPTB had a higher percentage of trophoblasts with short telomeres (47.6%) compared to NTP (15.6%, P < 0.0001). Aggregate formation was enhanced in SPTB (7.8%) compared to NTP (1.98%, P < 0.0001). Maternal blood and placental samples from SPTB had shorter telomeres and increased Gal-3 expression compared to NTP. These findings suggest that increased senescence and inflammation might be factors in the abnormal physiology of spontaneous preterm labor.

Low lying placenta: natural course, clinical data, complications and a new model for early prediction of persistency.

OBJECTIVE: To define the natural course and complications, and develop a model for predicting persistency when low-lying placenta (LLP) is detected early in pregnancy. METHODS: This retrospective cohort study included women with LLP detected during an early anatomic scan performed at 13-16 weeks gestation. Additional transvaginal ultrasound exams were assessed for resolution at 22-24 weeks and 36-39 weeks. Patients were categorized as: Group 1-LLP resolved by the second-trimester scan, Group 2-LLP resolved by the third trimester, or Group 3-LLP persisted to delivery. Clinical and laboratory parameters, as well as maternal and neonatal complications, were compared. A linear support vector machine classification was used to define a prediction model for persistent LLP. RESULTS: Among 236 pregnancies with LLP, 189 (80%) resolved by 22-24 weeks, 25 (10.5%) resolved by 36-39 weeks and 22 (9.5%) persisted until delivery. Second trimester hCG levels were higher the longer the LLP persisted (0.8 ± 0.7MoM vs. 1.13 + 0.4 MoM vs. 1.7 ± 1.5 MoM, adjusted p = .03, respectively) and cervical length (mm) was shorter (first trimester: 4.3 ± 0.7 vs. 4.1 ± 0.5 vs. 3.6 ± 1; adjusted p = .008; Second trimester: 4.4 ± 0.1 vs. 4.1 ± 1.2 vs. 3.8 ± 0.8; adjusted p = .02). The predictive accuracy of the linear support vector machine classification model, calculated based on these parameters, was 90.3%. CONCLUSIONS: Persistent LLP has unique clinical characteristics and more complications compared to cases that resolved. Persistency can be predicted with 90.3% accuracy, as early as the beginning of the second trimester by using a linear support vector machine classification model.

The Effect of External Cephalic Version on Fetal Circulation: A Prospective Cohort Study.

External cephalic version (ECV) is a cost-effective and safe treatment option for breech presentation at term. Following ECV, fetal well-being is assessed via a non-stress test (NST). An alternative option to identify signs of fetal compromise is via the Doppler indices of the umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV). Inclusion criteria were an uncomplicated pregnancy with breech presentation at term. Doppler velocimetry of the UA, MCA and DV were performed up to 1 h before and up to 2 h after ECV. The study included 56 patients who underwent elective ECV with a success rate of 75%. After ECV, the UA S/D ratio, UA pulsatility index (PI) and UA resistance index (RI) were increased compared to before the ECV (p = 0.021, p = 0.042, and p = 0.022, respectively). There were no differences in the Doppler MCA and DV before or after ECV. All patients were discharged after the procedure. ECV is associated with changes in the UA Doppler indices that might reflect interference in placental perfusion. These changes are probably short-term and have no detrimental effects on the outcomes of uncomplicated pregnancies. ECV is safe; yet it is a stimulus or stress that can affect placental circulation. Therefore, careful case selection for ECV is important.

Head position and vacuum-assisted delivery using the Kiwi Omnicup.

OBJECTIVE: To evaluate the association between fetal head position during prevacuum assessment and adverse outcomes. METHOD: This retrospective cohort study included all vacuum-assisted deliveries using the Kiwi Omnicup over 5 years. Primary outcomes were third- or fourth-degree perineal tear, pH < 7.1, and subgaleal hematoma (SGH). AGAR, neonatal intensive care unit admission, cephalohematoma, Erb's palsy, third-stage duration, and postpartum hemorrhage were secondary. Outcomes were compared between the occiput posterior (OP) and occiput anterior (OA) positions. RESULTS: The study included 1960 patients. OP position was more likely to involve epidural analgesia (311 [82.5%] vs. 1216 [77%], P = 0.020), higher fetal head station (P = 0.001), higher percentage of cup detachments (121 cases [32.1%] vs. 307 [19.4%], P = 0.001), and longer procedure (5.5 ± 3.7 min vs. 4.7 ± 2.8 min, P = 0.001). OP was associated with umbilical cord pH < 7.1 (21 [5.5%] vs. 52 [3.9%], P = 0.032), NICU admissions (16 [4.2%] vs. 38 [2.4%], P = 0.049), SGH (18 [4.8%] vs. 38 [2.4%], P = 0.013), and high-degree perineal tears (12 [3.2%] vs. 26 [1.7%], with borderline significance, P = 0.051). SGH and high-grade tears remained significantly associated with OP position (P = 0.008 and P = 0.016, respectively) after adjusting for maternal age, nulliparity, diabetes, epidural anesthesia, preprocedure head station, and birth weight. CONCLUSION: OP position is an independent risk-factor for anal sphincter injury and SGH during vacuum-assisted delivery.

Can We Predict Feto-Maternal Adverse Outcomes of Vacuum Extraction?

Introduction Vacuum extraction (VE) is an important modality in modern obstetrics, yet sometimes results in maternal or neonatal adverse outcomes, which can cause a lifetime disability. We aimed to characterize potential risk factors for adverse outcomes that in retrospect would have led the physician to avoid the procedure. Materials and Methods Retrospective cohort of 3331 singleton pregnancies, ≥ 34 w delivered by VE. 263 deliveries (7.9%) incurred a VE-related feto-maternal adverse outcome, defined as one or more of the following: 3-4th-degree perineal laceration, subgaleal hematoma, intracranial hemorrhage, shoulder dystocia, clavicular fracture, Erb's palsy or fracture of humerus. 3068 deliveries (92.1%) did not have VE-related adverse outcomes. Both groups were compared to determine potential risk factors for VE adverse outcomes. Results Multivariable regression found seven independent risk factors for VE-related feto-maternal adverse outcomes: Nulliparity - with an odds ratio (OR) of 1.82 (95% CI = 1.11-2.98, p = 0.018), epidural anesthesia (OR 1.99, CI = 1.42-2.80, p < 0.001), Ventouse-Mityvac (VM) cup (OR 1.86, CI = 1.35-2.54, p < 0.001), prolonged second stage as indication for VE (OR 1.54, CI = 1.11-2.15, p = 0.010), cup detachment (OR 1.66, CI = 1.18-2.34, p = 0.004), increasing procedure duration (OR 1.07 for every additional minute, CI = 1.03-1.11, p < 0.001) and increasing neonatal birthweight (OR 3.42 for every additional kg, CI = 2.33-5.02, p < 0.001). Occiput anterior (OA) position was a protective factor (OR 0.62, CI = 0.43-0.89, p = 0.010). Conclusions VE-related adverse outcomes can be correlated to clinical characteristics, such as nulliparity, epidural anesthesia, VM cup, prolonged second stage as indication for VE, cup detachment, prolonged procedure duration and increasing neonatal weight. OA position was a protective factor. This information may assist medical staff to make an informed decision whether to choose VE or cesarean delivery (CD).